We Don't Want Elitists To Fix Healthcare

Elites are fine. Elites are people with a lot of money and who attend the best colleges and universities. They end up with lots of knowledge and a lot of money. They are generally the people who end up with important jobs, such as lawyers and politicians. 

So, I don't have a problem with Elites. What I have a problem with is elitists. These are Elites who think they they know what's best for you, and they ought to have the power to control your life. In other words, they are smarter than you and their ideas should replace whatever systems are in place. And this is exactly what some of them intend to do for healthcare. 

And it's by this means that things like Obamacare got passed. Obamacare has some great ideas in it. But many of the things in it had never been tried before. So, they were untested. The only way they made the bill was because elitists decided they knew better than the systems already in place. And that's how we got this system where hospitals do not get reimbursed for COPD patients who are readmitted within 30 days, a system that has caused many smaller hospitals to merge with larger ones. 

So, let's discuss systems already in place. What are they? Why are they in place? Well, most of the systems we use were developed over thousands of years. They evolved over time and have been tested over and over. That doesn't mean they are the best systems. But they are the best systems that mankind has ever thought of. They are there for a reason. 

Then we have chimeras. These are ideas that elitists get into their head. And they think their ideas are better than the systems already in place for thousands of years. And their ideas have never been tried or tested. And that, despite this, they will be better than the systems already in place. They need to come up with evidence proving their ideas are better. But this rarely happens. And it didn't happen when Obamacare passed. And this is why you heard people like Nance Pelosi saying things like, "We need to pass it before we know what's in it." 

Elitists are the ones who tried to remake our healthcare system. They got this bright idea and now we have to live with it. 

What Determines Success?

Prepare for the worse and hope for the best. 

We are health care providers. We are nurses and respiratory therapists. Our success is not determined by how many sick people we care for. Our success is determined by how many people don't need our services.

Look at asthmatics as a good example. Back in the 80s, it was common to have sick asthmatics. In fact, it got so bad that asthma organizations were formed. Heads of these organizations, along with many of the top asthma research physicians in the world, put their heads together. They created asthma guidelines.

Today, regional asthma doctors are educated on how best to treat their asthmatic patients. Asthmatics themselves, in turn, are well educated how to stay healthy and out of hospitals. And it was a huge success. Today, we don't see a fraction of asthmatics we used to.

See, that is a success. The fact that most asthmatics are able to stay out of hospitals is a success. If they were still being admitted at record levels, that would not be a success. Sure, we would make more money if asthmatics were filling hospital beds. But, that they are breathing easy and avoiding us is a good thing, not a bad thing.

COPD right now is at epidemic levels. There are COPD patients getting admitted every day. There are also many COPD patients that become regulars. They are discharged and readmitted on a regular basis. That, my friends, is not a sign of success. It is a sign that we are failing them.

Let's talk intubation.

You don't want to intubate people. Sure, it's very profitable when we have ventilators. Sure, it might stimulate your excitement level. But, it's not something that's good. It's a last-ditch effort to save a life. It's nice that we have that skill. It's nice that we know how to save lives this way. It's great that we manage ventilators.

But it's not something we should look forward to. Someone comes in the door of the ER, we should be praying that they don't need us. We should be hoping they get better. But, I'm afraid there are many of us who hope, maybe even pray, that we get to intubate.

That is a sign of failure, not a success. Success is not needing to intubate.

Obviously, some people LOVE intubating. That's understandable. You want to do it to keep up your skill level. And Managers WANT ventilators. In most instances, they are very profitable for respiratory therapy departments.

But hospitals, especially the not-for-profit variety, are not in the market to make a profit. That's the whole point. We are here in case we are needed. We are the cost of being in the healthcare business.

Here's How Insurance Companies Gained Control Over Doctors and YOU

So, my pharmacist says I can only get one inhaler a month. I cannot buy one until it's been 30 days since I bought that last one. So, what gives insurance companies the power to control you like this? Let's discuss.

I'm going to borrow a quote from the Heritage Foundation, "The Cure: How Capitalism Can Solve The Healthcare Crisis." Here is the quote.

"There is the golden rule: He who controls the gold makes the rules. If the gold is controlled by the government, the government will make the rules, and you will do exactly as you are told. That's how it works. It's a law of nature. It's like the law of gravity: It's not something you can escape. That's the reality."

 In America we have a system of only a few insurance companies. This is not the fault of capitalism. It is the fault of too much government. I explained this in my post, "Discussing Healthcare Solutions."

If you have too many regulations on insurance companies, only those with the most money will be able to continue on. These wealthy insurance companies can afford to lobby Congress. They champion for more regulations as they know this will make it impossible for their smaller competitors to continue. And eventually all we are left with is these larger insurance companies.

We let this happen. It was the result of too much government control. Government control is what we wanted as this was supposed to fix the problem. But, it has only made it worse. And, to go back to our quote above, "He who controls the gold controls you."

That is how insurance companies get to tell you what you can get and how much you can get.

Back when there was lots of competition, these insurance companies did not have this power. So, in that older system insurance companies yearned to offer a product you wanted at a price you could afford.

If this meant filling the prescription exactly as ordered by the doctor, then so be it. That was how I was able to get three albuterol inhalers every time I picked up a prescription at the pharmacy. And sometimes I did this more than once a month. The insurance company wanted to keep me happy so I continued to stay with them.

Today, however, toss making us happy out the window. With little competition, these insurance companies have grown large. They are, in essence, monopolies. And they get to set the rules. And one of their rules is you can only get one inhaler a month, even if your doctor orders more; even if you NEED more.

So, now you know. It is not capitalism that allowed this to happen. It was our eagerness to allow Congress to fix the problem. And usually this means more government, not less. And therein lies the problem. Many blame capitalism. But, the truth is is, capitalism is the solution. Get rid of or at least cut back regulations. Create space for smaller competitors to enter the market. This is the only way to gain control back from these insurance monopolies.

Discussing Healthcare Solutions

Going where no one else wants to go. We’re mature adults, so I think we can have this discussion. We can be nice. And this is how I would like to discuss healthcare solutions. Let’s begin.

First, what do I think? You get your chance below.

Okay, let’s just get it out into the open. Many of my friends think the government is the solution. They want universal healthcare. They say it works in Canada. They say it works in Britain. They say it works in this country or that country.

Yet, when I talk to people from those countries, they aren’t happy about their healthcare either.

So, is government really the answer. It seems to me the government has been tinkering with healthcare since before I was born. And the problems keep getting worse and worse, not better and better.

Democrats do this. And so too do republicans. Look at Mitt Romney in Massachusettes. Look at Trump, who wanted to replace Obamacare with Trumpcare. It’s all government controlled, just different strategies for controlling. And, quite frankly, as an asthmatic I have seen inhaler prices spike faster than a speeding bullet. And this is way more than the rate of inflation.

And where has government control of healthcare gotten us? It’s made it almost impossible for insurance companies to stay in business. The only insurance companies still around are the ones who can afford the most expensive lobbyists. They lobby for things like Obamacare, which in turn make it even harder for their competitors to stay in business. And so their competitors go out of business, and they end up with large insurance monopolies.

Ditto for large hospital groups. They have been eating up smaller hospitals that have been regulated out of business. Government has created so many regulations that these smaller hospitals can no longer afford keep their doors open without signing merger agreements with these larger hospital groups. Just go to the ER for asthma and you will see first hand this has in no way resulted in lower healthcare prices. I recently paid more than $700 for an ER doctor to prescribe me prednisone

Ditto for pharmaceuticals. Now we often refer to them as “Big Pharma” and we often blame them for the expensive asthma medicines. We say they are greedy. But, let’s be honest here, if I was the CEO of a “Big Pharma company, and I had the power to get rid of my competition simply by lobbying congress, I would do it in a heartbeat. It’s just smart business.

So, it’s not Big Pharma, and it’s not big insurance, and it’s not big hospitals, that are responsible for this crisis. And, yes, it is a crisis. When asthmatics can no longer afford the medicines they once paid for out of pocket, it’s a crisis. And sorry, I don’t think it’s the fault of these companies. Now, they are definitely not innocent here. But, the main fault can be put on the feet of Congress.

It just seems like every time there’s a problem someone in Congress sees it as an opportunity. They say things like, “Ah, you have a problem. What can we do to help? What can we do to buy your vote. And of course they buy it with other people’s money. Ah, let’s create another bill. Let’s create another regulation. Let’s create more government.”

They say it will work. They convince us it will. And the end result is it never does. And they they attempt to solve it with even more government. And it still doesn’t work. And yet we keep supporting for and voting for this nonsense.

What I propose is the exact opposite.

I do not know anyone, republican or democrat, who is happy with the current healthcare system. And the current approach to healthcare is government involvement. And obviously it is not working. So why not do the opposite.

Why not try capitalism?

It’s the only option that has never been tried with healthcare. Many of my friends say it won’t work. But how do they know when it’s never been tried.

What happens when half the people get free or discounted healthcare? The answer is everyone who pays has to pay more to make up for those who don’t pay. And if everyone has free healthcare, then people who work will still have to pay for it anyway through higher taxes. So, either way people like me are going to pay for your free healthcare. And let’s be honest here, people like me are barely getting by as it is.

As noted above, big pharma became big pharma because their competition went under. And the less competition the higher the prices. It’s simple economics 101. And this is what has happened with healthcare. The price of healthcare has risen higher than people can afford. It has risen faster than what a capitalistic market would allow.

For example, a store that charged $100 for a gallon of milk would go out of business in a capitalistic system. The businesses that stay are those that have a great product or service at the best price. And the more competition you have the better the product or service and the lower the price.

Another problem with healthcare right now is there’s little incentive for smart people with great ideas to jump into the healthcare arena. So this limits creativity and it limits options. So, there could be someone out there with a better product, a better medicine, maybe even a cure for asthma. But we won’t see it because our current system blocks that person from entering the arena.

And that’s why capitalism is so great. People have the potential to make profits by creating products or services that we want or need. They can make a profit off making our lives better. Their success is determined by how well they meet our needs. That’s capitalism.

So, my solution to the healthcare crisis is to get the government out of it.

Give capitalism a try.

Why is healthcare a such mess? How can it be fixed?

Your Question:  The healthcare system is a mess.  How did it get this way? What is the solution?

My Answer:  Let me start by saying that in front of me right now is a bill from Paula Sterns Hospital in Ludington, Michigan, from March of 1943.  It is the bill for my grandma's entire three day stay when she had my dad.  The cost was $23.00.  The ambulance bill was $2.  If you adjust these bills for inflation, they come to $317.26 and $27.59.

The cost of just one breathing treatment today is $123.00, so you can easily see that something occurred in healthcare that inflated the cost of it by a stunningly high margin way over the rate of inflation.  What happened was that, during the 1960s, the progressives decided that the healthcare system was messed up and they could fix it. So they created regulations. So now hospitals have to hire people to make sure the regulations are met.  To pay these people the cost of healthcare increases.

In the 1970s they realized that the prices were too high for many people, so they had to come up with another solution. This time they created medicare and medicaid and DRGs and more regulations.  To make sure regulations are met, more people must be hired.  To cover the cost, prices go up.  But now people still can't pay, so third party system is created.  So now the hospital bill does not come directly from the hospital at all, but from insurance companies.  So not only do you have to pay the hospital bill, now you have to pay an insurance bill as well.

So this is the system until 2010.  Now you have healthcare prices that have skyrocketed beyond belief. You have 40 million people who have no insurance at all, some by choice and some not by choice.  You have the same people who messed up the system in the first place try to fix the problem, once again, with more government.  More regulations are created.  Hospitals now have to hire hundreds more personnel just to make sure regulations are met.  This is done at the expense of patient care, even though it is meant to improve patient care.  Instead of prices dropping, they skyrocket once again.

So who is going to solve the problem now.  Hopefully not the government.  The government got involved in healthcare during the 1960 and created the same problems they propose to fix.  And the more they try to fix it with their ideal solutions the more they make it worse.  They do not ever solve the problems they propose to fix, they only succeed at creating chaos.

The solution to all of this is simple: let capitalism work.  That's the only thing that has not been tried, at least since the 1960s.  When you go to the hospital to seek a service, you should get a bill from the hospital for that service.  The price would not include any middlemen, and therefore would be very inexpensive, like it was in 1943 when my grandma only paid $25 for an entire hospital stay.

Surely the price would be a little higher due to inflation and technology, but price of healthcare today is beyond reasonable.  Why? Because, back in the 1960s, government officials, sitting around a table in leather chairs drinking coffee, decided they could make it better.  Did they? Absolutely not.  These people need to get out of the healthcare industry, and let the people, the markets, the states, solve the healthcare crisis.

The real solution is capitalism. Here you would have individual hospitals compete for your services.  What one hospital did best to win you over, other hospitals would copy.  When one hospital creates a program that fails, other hospitals will not copy that program. That is what's needed. Competition is the best method of driving down prices.  If you charge too much, people can go somewhere else.  If you provide good service at a good price, then your hospital will be the one chosen.

I am not naive.  I understand there are outside forces involved in price increases.  There is better technology today, there is better education that costs more, etc.  But, still, the healthcare solutions since the 1960s have all come from Washington, and everyone of them has failed to solve the problem.  And so many people say, "Well, what else can we try?"  I propose to try capitalism, because it is the only solution that has yet to be tried -- at least not since 1943.

Are 'death panels' coming back?

Obama and I have our differences, but when it comes to end of life care we seem to see eye to eye. I think.

It is simply a fact that doctors need to (er, should) have that talk with their patients regarding end of life care. Doctors must (should) explain end of life care, and must have patients fill out advanced directives.

The difference Obama and I have regarding this matter is how such a directive should be enforced. I tend to agree with men like Thomas Jefferson, James Madison, James Monroe, and Grover Cleveland, that such matters should be dealt with by the states and not the federal government.

I bring this up because of an LA Times article titled "Obama Administration Revives Plan Once Criticized as Death Panels."  If the government gets to decide who lives and who dies, then I'm out.  If the government gets to decide that a 90 year old grandma cannot get the pacemaker she needs and wants, then I'm out.  If the government decides who lives or dies, I'm out.  This is unacceptable in my book. This is the end of the slippery slope I think conservatives are worried about, and how terms such as "death panels" came about.

If the government is just doing this to save money, then I'm definitely out.  When it comes to saving lives, money shouldn't matter. Human life is more precious than anything else on earth, even the earth itself.

However, if the goal is noble, then I'm all in.  If the goal is to get people to make smart decisions about end of life care, then I'm in.  I see too many people who want chest compressions and intubation who have no idea what that means.  Too many people get it all when they shouldn't.  I mean, I certainly don't want to be pounding on grandma's chest.  If that's what grandma wanted, I'm fine with that. But a responsible doctor would have at least had that talk with her at some more (hopefully by choice and not by mandate).

So, it should be grandma's decision and not Uncle Sams.  The government should have no say in who lives or who doesn't.  And I certainly don't think the government should even get involved in this.  They should not even offer negative incentives, such as they do with reimbursement criteria (if you don't do this we're paying you less.  Negative reimbursement is basically a nice way of saying you have to do it or else. There really isn't much of a choice there.

Still, I think it's a noble cause if it's done right.  It's a noble cause if there's an educational campaign that goes on, and not an Uncle-Sam-is-going-to-force-you-to-do-this-and-everyone-over-the-age-of 70-will-now-be-a-DNR-campaign.  I think doctors should be encouraged to talk to their patients about end of life care. It would be a noble public relations campaign to get into -- but it should not be a law, nor a regulation, nor a mandate.

Further reading:

• RT Cave: How Do People Die
• RT Cave: Most People Will Not Survive CPR, but many want it anyway
• RT Cave: Is It Okay To Keep Patient Alive Until Family Arrives?
• RT Cave: Believe It Or Not, You Will Eventually Die
• RT Cave: The Elderly Are The Seat Of Wisdom
• RT Cave: He Died Peacefully In His Sleep
• Wall Street Journal: How Doctors Die Differently

Healthcare: Quality -vs- Quantity

As an advertising student at Ferris State University, we learned about quality versus quantity.  We learned that you could reach a lot of customers a few times with your ads, or you can reach a few customers many times with your ads.  You cannot do both.  You can either have quantity or quality.

Justin Williams, in describing the dilemma of quality versus quantity in marketing, said that "In a perfect world, a brand sends the perfect number of perfectly composed emails to elicit the maximum response possible. In the real world, email marketers must balance between quantity and quality."

I think about this often as I'm doing my work as a respiratory therapist.  On some days I have only a few patients, and they get 100% of my attention all the time.  Sometimes I'm able to sit and talk to them, and this type of social interaction brings joy to both me and my patients.  Other times I can spend more time assessing my patients, resulting in them getting better care.  

On these days, when the emergency room calls, they have my undivided attention right away.  When a nurse or hospitalist needs my services, they have my undivided attention right away. This results in better patient care, better coworker satisfaction, and better satisfaction for myself too.  

On other days, however, I have many patients, and doctors are writing many orders.  On these days I'm hard pressed to get my work done in a timely manner.  I usually get it done, yet at the end of the day I'm often left wondering if I could have given better care.  I never feel satisfied at the end of these days.

On the other hand, some say that we as RTs accomplish more on the busy days, and therefore should feel good about ourselves.  It's being busy like this that results in us keeping our jobs and the hospital making money.  Yet what those people fail to see is that such busy days result in quantity at the expense of quality. You see, you can't have it both ways.  

I think of this when my coworkers complain when it's too busy.  I think of this when my RT friends online tell me how overwhelmed they feel at work.  I think of this when nurses complain that they have too many patients due to poor staffing.  

Keep in mind here that sacrificing quality for quantity is not all the hospitals fault, nor the physician's fault. For instance, it's not their fault, on certain days, weeks and months, every person with a chronic disease gets sick and requires the services of a hospital.  Technically speaking, there's no way to plan for these busy days.

An ongoing conundrum of the healthcare industry, as well as any other industry, is finding the perfect balance between quality and quantity.

Yet in healthcare, this is a time tested challenge that may never be overcome.  For instance, store managers can look at sales from April to May last year and plan for this year based on last year's sales.  It's not so easy to do in healthcare, mainly because it's impossible to know when people will get sick.  

To twist Justin William's words for our own purposes:  "In a perfect world, a hospital staffs the perfect number of perfectly performing physicians, nurses, and respiratory therapists to elicit the maximum care possible. In the real world, staffing is a balance between quantity and quality."

Waste in healthcare

Becker's Hospital Review has a nice little write up called the 8 Types of Waste in Healthcare.  I think the article is great.  I have posted the article below, and I have added my own comments in red.

The term "waste" encompasses an array of definitions for hospitals and health systems, including wasted time, finances, steps and human potential, to name a few.  The profession of respiratory therapy is a perfect example of wasted potential.  Studies have proven that about 80% of the procedures performed by respiratory therapists is either a waste of time or delays time.  

Here are eight types of waste in healthcare, as defined by Mark Graban in his book Lean Hospitals, and shared in Ernst & Young's Health Care Industry Report 2013.

1. Defects. This includes all time spent doing something incorrectly and inspecting or fixing errors. One example of defect waste is the time spent looking for an item missing from a surgical case cart. In the 30 years I've been in the profession I can attest that administrators are more concerned with that you charted as compared with that you helped a patient. 

2. Over-production. This includes doing more than what is needed by the patient or doing it sooner than needed. A broad example of this is the performance of unnecessary diagnostic procedures.  An even better example is EKGs.  Since it's so easy to do, EKGs are a part of nearly every order set in the hospital.  Most EKGs that are ordered are merely to make sure a doctor (or hospital) covers his bases to make sure he doesn't get sued or to make sure the hospital gets reimbursed. Most EKGs are a complete waste of time.  

3. Transportation. Unnecessarily moving patients, specimens or materials throughout a system is wasteful. This type of waste is evident when the hospital has a poor layout, such as a catheter lab located a long distance from the emergency department.  Most RT departments are located in whatever space is left over after every other department is settled.  Most RT departments are stuffed in basements, old closets, or even old shacks on the other side of a river across the street from the hospital.  

4. Waiting. Waiting for the next event to occur or the next work activity can eat up time and resources. Patients waiting for an appointment is a sign of waste, as is employees waiting because their workloads are not level. If I had a dime for every stat EKG I've been called to do only to have to wait 10 minutes for the nurse to put in an IV, or a catheter, or to check a rectal temp, I'd have retired twenty years ago.  
5. Inventory. Hospitals create waste when they incur excess inventory costs, storage and movement costs, spoilage and waste. One example is letting supplies expire and then disposing of them, including out-of-date medications.  Respiratory therapy departments are notorious for wasting medical supplies.  Probably about half of the endotracheal tubes in RT storage bins are yellow.  This is, however, not necessarily the fault of anyone in particular.  It's just one of the things that must occur when you have to be prepared for every occasion. 

6. Motion. Do employees move from room to room, floor to floor and building to building more than necessary? That accounts for one type of waste. Lab employees may walk miles per day due to a poor hospital layout, for example.  Studies show that respiratory therapists walk an average of 20 miles a day.  The main reason for this is to perform procedures that are a waste of time or delay time.  So for those of you who say these wasteful therapies make money for the hospital and keep us at work, they also result in lots of wasteful steps.  

7. Over-processing. This describes work performed that is not valued by the patient or caused by definitions of quality that aren't aligned with patient needs. One example is extra data stamps put onto forms, but that data never being used. This is over my head and between my legs. 

8. Human potential. This waste is caused when employees are not engaged, heard or supported. Employees may feel burnt out and cease sharing ideas for improvement.  Most respiratory therapists develop some type of apathy and burnout due to the fact that our talents and knowledge are rarely utilized.  I have had doctors order breathing treatments for a wheeze, even though the RT has notified the doctor that it wasn't a wheeze but a larygospasm, or cardiac wheeze, or otherwise not bronchospasm.  I have had doctors order BiPAP to offset the pressure from a bloated stomach, or to too tick a patient off and increase his blood pressure.  I kid you not.  It is no wonder so many RTs develop apathy, or as Mr. Frea says, RATS. 

With all due respect, however, it's pretty much like this in any profession whereby you work with people.  Apathy is pretty much something that sets in regardless of your profession, and this should not be a reason to avoid the respiratory therapy profession.  We're just having fun here on this site. 

RT Cave Facebook Page

RT Cave on Twitter

Wonderful things in the healthcare air

I find that there are some wonderful things happening in healthcare lately.  I see hospitalists being gentle and kind to their patients, and kind to nurses and respiratory therapists.  I see ER doctors likewise being cordial and amiable.  I'm not sure what's in the air, but whatever it is, I like it.

Today I was in the emergency room and was doing an ordered EKG on a patient, and the patient said, "I could really go for one of your treatments.  Albuterol really works well on me."

"Well," I said, "then I'll stop doing this and get you a treatment."  I did.  I stopped doing the EKG and whipped up a albuterol treatment.  Then I did the EKG and took it to the doctor.

Now, in the past, there were some doctors who would be grumpy control freaks. They insist that nothing be done until they order it, no matter what.  So there was a risk in thinking for myself.

So I handed the doctor the EKG and I said, "So, do you mind if I give him a treatment."

He said, "I want you to.  I just ordered it."

I said, "Oh good, I already started it."

He said, "Great job!  Great minds think alike."

Wonderful things are in the air.  I like this new friendly milieu

RT Cave Facebook Page
Rick Frea's Facebook
RT Cave on Twitter